protein energy malnutrition - gmch.gov.in lectures/community medicine/pem.pdf · waterlow’s...
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V1
Protein Energy Malnutrition
Facilitator:
Dr. NAVPREETAssistant Professor of Community MedicineGovt. Medical College & Hospital, Chandigarh.
Specific Learning Objectives
• At the end of session, the learner shall be able to:Understand the concept of PEM.
Describe factors associated with PEM.
Classify PEM.
Take preventive measures for PEM.
Introduction
• Malnutrition is a range of conditions occurring when intake of one or more nutrients doesn’t meet the requirements.
• PEM
is
an
important
nutritional
problem
among
preschool age children.
• The main cause of PEM is food inadequacy.
• PEM
was
earlier
attributed
to
the
concept
of
‘protein
gap’ (deficiency of proteins in diet).
• ‘Food gap’
is the chief cause of PEM
it is not only the deficiency of proteins but inappropriate food (low
in
energy
density,
protein
and
micronutrients ‐
Vitamin
A, Iron, Zinc)
poor both quantitatively and qualitatively.
Undernutrition
Underweight being underweight for one’s age(Weight for age)
Stunted being too short for one’s age(Height for age)
Wasted being dangerously thin(Weight for height)
Micronutrient malnutritionbeing deficient in vitamins and
minerals (Hidden Hunger)
Magnitude of the Problem
• World
More than 1/3 of the world’s population.
For
all
indicators
of
PEM,
a
total
of
80%
of
the
children affected live in Asia (mainly in southern Asia).
43% of children in developing countries are stunted.
50%
of
child
deaths
in
developing
countries
are
related
to malnutrition
5145 43 40
20 23
0
10
20
30
40
50
60
Stunted Underweight WastedNFHS-2 NFHS-3
Undernutrition in Children under age 3 years in INDIAPe
rcen
t
Children’s Nutritional Status in INDIA
Children under age 5 years who are underweight (%)
2022 23
25 25 25 26 2630
33 3336 37 37 38 38 39 40 40 40 41 42 43
4547
49
56 5760
20
0
10
20
30
40
50
60
70
SK MZ
MN KE PJ GA
NA JK DL
TN AP
AR AS
HP
MH KA
UT
WB
HR TR RJ
OR UP IN GJ
CH
MG BH JH MP
Factors associated with PEM
• Ante natal and post natal care• Low birth spacing• Feeding practices• Rural Urban distribution• Gender and PEM• Infections & environment
• Literacy• Socioeconomic status of family
Socio‐cultural practices
Malnutrition – Infection Vicious cycle
Classification of PEM
• PEM is a spectrum of conditions ranging from growth failure to overt marasmus or kwashiorkor.
• Various classifications are given Gomez classification IAP classificationNCHS (WHO) classificationWaterlow’s classificationWelcomes classification
Gomez classification
• Based on Weight for age.
• In
this
system
the
normal reference
child
is
the
50th
centile
of
the
Boston standard.
• Weight for age (%) =
(Weight
of
the
child
/
Weight of the normal
child
of
same age ) X100
Stage of MalnutritionWeight for
age (%)
Normal > 90 %
Grade I 75 – 90 %
Grade II 60 – 75 %
Grade III < 60 %
• Gomez classification is easy to use because weight is very easy to measure
• Disadvantages are :A cut of point of 90 % is high (80 % is equivalent to –
2SD
or
3rd
percentile)
so
some
normal
children
are classified as grade I malnutrition.
Only weight is measured so it is difficult to know that if
the
low
weight
is
due
to
an
acute
malnutrition
or
long standing chronic malnutrition.
Boston
standard
used
in
above
classification
is
no longer an international reference data.
IAP classification(1972)Also based on Weight for age.
Stage of Malnutrition
Weight for age (%)
Normal > 80 %
Grade I 70 – 80 % Mild
Grade II 60 – 70 % Moderate
Grade III 50 ‐
60 % Severe
Grade IV < 50 %
WHO classification (based on NCHS data )
Median
used
here
is
the
Median
weight
of
NCHS reference population.
Weight below Median minus 2SD ( M ‐
2SD)
Moderate malnutrition
Weight below Median minus 3SD ( M – 3 SD)Severe Malnutrition
Waterlow's classificationBased on Weight and Height
W/HH/A
> m – 2 SD < m – 2 SD
> m – 2SD Normal Wasted
< m – 2SD Stunted Wasted And Stunted
Drop in Height for age (< 90%) Stunted
Drop in Weight for Height (<80%) Wasting
Drop in Weight for Age (<80%) Under weight
Wellcome’s classification
• Parameter: Weight for age +
oedema
• Reference standard (50th percentile)• Grades:80‐60 % without oedema is under weight
80‐60% with oedema is Kwashiorkor
< 60 % with oedema is Marasmus‐Kwash
< 60 % without oedema is Marasmus
19
Mid‐arm circumferenceMAC does not vary much between age of 1 – 5 years.
MAC > 13. 5 cm Satisfactory nutritional status
MAC 12.5 –
13.5 cm Mild to moderate malnutrition
MAC < 12.5 cm Severe malnutrition
V2
Complications of PEM
• Water, electrolyte and mineral imbalance• Hypothermia• Hypoglycemia• Superadded infections• Vitamin deficiency• Lactose intolerance• Cardiac failure• Bleeding tendency• Renal impairment• Long term – Growth retardation, mental retardation
22
Preventive measures
Think – Pair – Share
23
A)
Health Promotion:• Measure
direct
to
pregnant
and
lactating
women
(education, supplements)
• Promotion of breastfeeding
• Development of low cost weaning food
• Family planning
• Home economics
• Family environment
25
B) Specific protection:1.
Protein energy rich food (e.g. milk, egg, fresh fruits)
2.
Immunization3.
Food fortification
C) Early diagnosis and treatment:1.
History taking
2.
Clinical features3.
Anthropometry
4.
Biochemical and laboratory investigations.5.
Proper and effective management.
26
D) Rehabilitation:1.
Hospital treatment
2.
Nutritional
rehabilitation
services
(NRC
i.e. Nutritional Rehabilitation Centres)
3.
Follow‐up care
Success Stories...
27
Take Home Message!
• Malnutrition does not mean undernutrition.
• There are various classifications for PEM.
• PEM is preventable and curable.
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